This is kind of unbelievable but true, I just switched to Humana PPO from Blue Cross / Blue Shield because no PPO is offered in Texas this year. Well, my MD Anderson myeloma specialist put in for my Revlimid 10 mg prescription for maintenance as I just completed my transplant and the results are good. To my horror and utter disbelief, Humana second-guessed the specialist and denied the prescription, even upon appeal, stating that it was NOT medically necessary.
We are in a state of shock and do not know what to do as I am in a high risk category.
Please let us know if anyone has had such an experience and how did you manage such a situation.
Kind Regards
Frank
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Re: Humana denies Revlimid maintenance prescription
Wow, seventy (70) views and zero (0) replies, I guess I am the only one who has had his Revlimid subscription declined by an insurance company, though I am not surprised.
Re: Humana denies Revlimid maintenance prescription
Is there some sort of appeal board you can appeal too? I dunno, I'm in Canada, and if the provincial government says no to a treatment, there is an appeal board.
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Little Monkey - Name: Little Monkey
- Who do you know with myeloma?: Father-stage 1 multiple myeloma
- When were you/they diagnosed?: March/April of 2015
Re: Humana denies Revlimid maintenance prescription
DuckJibe,
I am following your post for obvious reasons. To answer your question, Humana has covered my Revlimid so far. I am 17 months from my most recent autologous stem cell transplant, low risk, and MRD negative.
Humana for the most part has been excellent. I am curious what is going on in your case
I am following your post for obvious reasons. To answer your question, Humana has covered my Revlimid so far. I am 17 months from my most recent autologous stem cell transplant, low risk, and MRD negative.
Humana for the most part has been excellent. I am curious what is going on in your case
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blueblood - Name: Craig
- Who do you know with myeloma?: Myself
- When were you/they diagnosed?: March 2014
- Age at diagnosis: 54
Re: Humana denies Revlimid maintenance prescription
Hello DuckJibe,
I have been studying the high cost of coverage, particularly if I lose the private insurance coverage from my wife's employer and go on a Medicare supplement plan. The high cost of Revlimid has bothered me in principle.
As a radically different approach have you discussed the thalidomide alternative with your oncologist? This may work as a stop gap measure in your case, till Humana approves Revlimid for you, as they should.
I have been thinking about it myself, particularly after reading some of the discussion about thalidomide. I definitely plan to discuss the thalidomide alternative with my oncologist. Also, all those that have lived with multiple myeloma since before Revlimid was even approved were using thalidomide for maintenance and I know of at least one specific case where the patient is still on thalidomide after maintenance after about 17 years. Also, I believe Revlimid is still not prescribed by the state run healthcare systems in many countries and they use thalidomide as a viable and economical alternative. The drug companies have often lobbied Medicare for marginally more effective drugs that are too costly to justify their use as 'standard of care'.
I have been studying the high cost of coverage, particularly if I lose the private insurance coverage from my wife's employer and go on a Medicare supplement plan. The high cost of Revlimid has bothered me in principle.
As a radically different approach have you discussed the thalidomide alternative with your oncologist? This may work as a stop gap measure in your case, till Humana approves Revlimid for you, as they should.
I have been thinking about it myself, particularly after reading some of the discussion about thalidomide. I definitely plan to discuss the thalidomide alternative with my oncologist. Also, all those that have lived with multiple myeloma since before Revlimid was even approved were using thalidomide for maintenance and I know of at least one specific case where the patient is still on thalidomide after maintenance after about 17 years. Also, I believe Revlimid is still not prescribed by the state run healthcare systems in many countries and they use thalidomide as a viable and economical alternative. The drug companies have often lobbied Medicare for marginally more effective drugs that are too costly to justify their use as 'standard of care'.
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K_Shash - Name: K_Shash
- Who do you know with myeloma?: Self
- When were you/they diagnosed?: November 2014
- Age at diagnosis: 67
Re: Humana denies Revlimid maintenance prescription
Hi,
I wasn't going to post this, but after reading Trevor's column I decided it might be helpful. I recently just went thru an appeal for my Revlimid maintenance renewal. Somehow there was an error in records that showed me on dex along with the Revlimid.
The denial said that my plan only approved Revlimid maintenance as a single agent and not a combo treatment. Since this was done in error my prescription was approved but this begs the question:
Why is an insurance company second guessing and overruling the myeloma specialist anyway?
Peace! BN
I wasn't going to post this, but after reading Trevor's column I decided it might be helpful. I recently just went thru an appeal for my Revlimid maintenance renewal. Somehow there was an error in records that showed me on dex along with the Revlimid.
The denial said that my plan only approved Revlimid maintenance as a single agent and not a combo treatment. Since this was done in error my prescription was approved but this begs the question:
Why is an insurance company second guessing and overruling the myeloma specialist anyway?
Peace! BN
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Bar-none - Who do you know with myeloma?: Me
- When were you/they diagnosed?: 3/14
Re: Humana denies Revlimid maintenance prescription
Frank,
Sorry to hear about the Revlimid coverage. I will be going on Medicare in July and due to my complicated situations, I went to a health and Medicare advisor. The person I spoke with went over all my Medicare supplemental and of course a Part D for prescriptions. My big concern was the Revlimid coverage. So she had me make a list of drugs that I take and might possibly take in the future. She checked all of them out and Humana actually covered the Revlimid with my co pay being $550.00. That's a huge co-pay but way less than the $10,000 cost.
My coverage for Humana Part D was calculated according to where I live. You would think that it would be the same everywhere. But I guess not. I have heard nothing but good things there at MD Anderson. There should be someone there that can make it happen for you. There has to be some error in the request for Revlimid. My last Velcade treatment had the code off by one number and it was denied.
Castaway
Sorry to hear about the Revlimid coverage. I will be going on Medicare in July and due to my complicated situations, I went to a health and Medicare advisor. The person I spoke with went over all my Medicare supplemental and of course a Part D for prescriptions. My big concern was the Revlimid coverage. So she had me make a list of drugs that I take and might possibly take in the future. She checked all of them out and Humana actually covered the Revlimid with my co pay being $550.00. That's a huge co-pay but way less than the $10,000 cost.
My coverage for Humana Part D was calculated according to where I live. You would think that it would be the same everywhere. But I guess not. I have heard nothing but good things there at MD Anderson. There should be someone there that can make it happen for you. There has to be some error in the request for Revlimid. My last Velcade treatment had the code off by one number and it was denied.
Castaway
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Castaway - Name: George
- Who do you know with myeloma?: just myself
- When were you/they diagnosed?: 1/24/14
- Age at diagnosis: 62
Re: Humana denies Revlimid maintenance prescription
Well, I have a happy update.
My doctor at MD Anderson prescribed Revlimid and Ninlaro because I am a high risk myeloma patient, as maintenance after my transplant and consolidation treatment. After being denied Revlimid even after appeal (they did approve Ninlaro!), I decided to contact Humana's assigned cancer nurse just to hear the justification for the refusal. I was not expecting much to happen.
The nurse could not believe that they denied the Revlimid, and promised to investigate. To my amazement , she called me back a couple days later to tell me that the Revlimid has been approved. I just could not believe my ears. I called Humana just to confirm and lo and behold it was approved!
This is a nurse worth her weight in gold! WOW! I am still in awe! She literally added years to my life!
Kind Regards,
Frank.
My doctor at MD Anderson prescribed Revlimid and Ninlaro because I am a high risk myeloma patient, as maintenance after my transplant and consolidation treatment. After being denied Revlimid even after appeal (they did approve Ninlaro!), I decided to contact Humana's assigned cancer nurse just to hear the justification for the refusal. I was not expecting much to happen.
The nurse could not believe that they denied the Revlimid, and promised to investigate. To my amazement , she called me back a couple days later to tell me that the Revlimid has been approved. I just could not believe my ears. I called Humana just to confirm and lo and behold it was approved!
This is a nurse worth her weight in gold! WOW! I am still in awe! She literally added years to my life!
Kind Regards,
Frank.
Re: Humana denies Revlimid maintenance prescription
Here in Florida, we have a state agency that oversees insurance companies and looks into complaints. Maybe you have something similar where you live? This is horrific! And it is proof of insurance companies dictating treatment, not the doctor. I would fight it tooth and nail. I am so sorry you are going through this.
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Mimi - Name: Mimi
- Who do you know with myeloma?: Husband
- When were you/they diagnosed?: October 2015
- Age at diagnosis: 58
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